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The PCMH RN Care Coordinator collaborates with healthcare professionals to facilitate healthcare delivery and ensure appropriate care for assigned patients. Responsibilities include identifying patients for care coordination, scheduling services, and maintaining communication with care teams.
Candidates must have a minimum of an Associate's Degree in Nursing and a current RN license in South Carolina, along with at least three years of nursing experience. Proficiency in computer skills and the ability to analyze data are also required.
Job Description Summary The role of the Patient-Centered Medical Home (PCMH) Care Coordinator III is a nurse that works collaboratively with the physicians, staff and other health care professionals to actively facilitate health care delivery and promote care team communication for an assigned patient population ensuring appropriate care is provided. This position will be remotely based, in the Beaufort area. This position will be required to round in clinics 1-2 days per month. Entity MUSC Health Partners (MHP) Worker Type Employee Worker Sub-Type Regular Cost Center CC000101 CFC PC Care Coordination Pay Rate Type Hourly Pay Grade Health-27 Scheduled Weekly Hours 40 Work Shift Job Description Job Duties Identifying patients that qualify for care coordination: not meeting clinical goals and quality measures (i.e. hypertension and diabetic control) for CCM pts, overdue for visits, labs, or referrals and arranging for follow-up services as appropriate for CCM pts, chronic care management (CCM), identify gaps in care and respond with appropriate action to correct. TCM coverage as needed. Utilizes Epic registries and reports in accordance with process (i.e. CCM-weekly & daily, quality measures) to identify patients and needs. Outreached to patients identified for care coordinator services (i.e. CCM, quality measures) & documents attempt (s) & completion. Scheduled services and places referrals in accordance with patient need (s) (i.e. vaccine, labs, appointment, mammogram, etc.) Follow up as appropriate to track data. Accurately maintains 100% of data received. Communicates effectively and professionally with patient (s), care team (s) and providers to provide support for continuity of care between patient, care team, and assigned providers Compiles and summarize information for quality measures and projects. Attend 80% of staff meetings. Maintains communication with providers & care team members (i.e. Epic inbox message, email, phone, office schedule, in person) Identify patient needs and/or barriers (psychosocial and other) to care and coordinate patients/families contact with community resources. Completes & documents accurate information gathering of data. Completes Epic & community referrals as needed. Communicates & follow up of identified barriers to the appropriate care team member/resource. Other duties as assigned. Additional Job Description Education and Work Experience Minimum Associates Degree in Nursing Current South Carolina RN required with a minimum three years’ experience as an RN. Computer skills to include proficiency in MS Word, Excel and PowerPoint. Working knowledge of an electronic medical record application. A team player that can follow processes to achieve a common goal. Highly organized and well-developed oral and written communication skills. Must be able to analyze and interpret data. Licensures, Registrations, Certifications: Current license as an RN in the state of South Carolina. Updated BLS. Physical Requirements: Continuous requirements are to perform job functions while standing, walking and sitting. Ability to bend at the waist, kneel, climb stairs, reach in all directions, fully use both hands and legs, possess good finger dexterity, perform repetitive motions with hands/wrists/elbows and shoulders, reach in all directions. Maintain 20/40 vision corrected, see and recognize objects close at hand and at a distance, work in a latex safe environment and work indoors. Frequently lift, lower, push and pull and/or carry objects weighing 50 lbs (+/-) unassisted, exert up to 50 lbs of force, lift from 36” to overhead 25 lbs. Infrequently work in dusty areas and confined/cramped spaces. Ability/willingness to travel frequently to MUSCP-PC clinical locations away from the main campus. If you like working with energetic enthusiastic individuals, you will enjoy your career with us! The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need. Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees Thank you for wanting to be part of the Medical University of South Carolina team. Whether you want to teach the next generation of health care leaders, innovate new business models, discover the next breakthrough or provide patient care, there's a role for you that fuels your passion and takes advantage of your skills. There are career opportunities available in academics, research, hospital medicine, physician practices and support services, from patient billing to IT. As an applicant, you can search jobs for all MUSC entities as well as search by category and location. MUSC attracts more than $250 million annually in research funding, making it the biggest magnet for biomedical, extramural research dollars of all institutions of higher learning in South Carolina. The Clinical and Translational Science Award (CTSA) Program aims to advance clinical and translational science to increase the speed at which new treatments become available to patients. MUSC Health, the clinical enterprise, operates a 750 bed medical center, which includes a nationally recognized Children’s Hospital, the Ashley River Tower (cardiovascular, digestive disease, and surgical oncology), Hollings Cancer Center (one of fewer than 70 elite National Cancer Institute designated centers), a Level I Trauma Center and the Institute of Psychiatry. In addition, there are more than 100 outreach clinics, hospital/health system affiliations, and telehealth sites. U.S. News & World Report placed us among the top one percent of all American hospitals, with 11 specialties in the top 50. The MUSC Medical Center is also one of only three Magnet® designated hospitals in South Carolina.
This job posting was last updated on 8/6/2025